Overuse of the ED – It’s not the players, it’s the game

January 12th, 2015

It’s been common knowledge for a long time that many lower-income Americans use hospital emergency departments for their primary care needs, rather than seeking care in physicians’ offices or other outpatient settings. Now, a new study from Health Affairs sheds some light on why – and the answers are troubling.

The study, conducted by researchers from Penn’s Perelman School of Medicine, consisted of interviews with 40 patients from Philadelphia with low socioeconomic status (SES), which the researchers defined as “low income and uninsured or on Medicaid,” according to a news release from Penn Medicine. The interviews were conducted by community health workers.

The interviewees generally stated that they “perceived [hospital care] as less expensive, more accessible, and of higher quality than ambulatory care,” according to the study. And they weren’t exactly wrong – especially when it comes to accessibility. Many low SES patients don’t have their own car and find it difficult to access various far-flung community resources – whereas the hospital is essentially a “one-stop shop.”

With regard to cost, the release states: “Uninsured patients often could not afford fees for regular visits to see a doctor or specialist, leaving them no choice but to rely on hospital charity care when they became ill. For patients covered by Medicaid, the direct financial cost of an emergency department visit and physician office visit were similar; however, the overall cost of outpatient care was higher because of the additional time and expense required for specialty visits or additional testing recommended by the primary care provider.”

The bottom line is that when poor people choose to utilize emergency room services rather than going to a primary care doc, they’re not being ignorant. They understand the system, and they’re making rational choices. The problem is the system itself. Indeed, the news release quotes David Grande, MD, MPA, assistant professor of Medicine at Penn Medicine and senior author of the study, as saying “[T]hese patients eloquently explained to us how we have built a health care system that incentivizes them to wait and get sick in order to get care that is more costly to society.”

Those costs won’t come down – and clinical outcomes for the poor won’t improve – until we finally achieve a system in which preventive healthcare is truly valued and backed by real financial incentives.